Research Report

A Tale of Two Cities: Understanding the Differences in Medical Professionalism Between Two Chinese Cultural Contexts Ming-Jung Ho, MD, DPhil, Kun-Hsing Yu, MD, Hui Pan, MD, Jessie L. Norris, MPH, ­You-Sin Liang, MPH, Jia-Ning Li, and David Hirsh, MD

Abstract Purpose To compare stakeholders’ constructs of medical professionalism in two Chinese cultural contexts.

authors analyzed NGT transcripts to construct a visual medical professionalism framework for PUMC and compared it with that of NTUCM.

Method Between November and December 2011, the authors adopted the nominal group technique (NGT) to elicit professional competencies valued by 97 medical education stakeholders at Peking Union Medical College (PUMC) in Beijing, China. Participants categorized the professional competencies according to an existing framework developed at National Taiwan University College of Medicine (NTUCM) in Taipei, Taiwan; they also modified and developed new categories for the framework. The

Results The Chinese stakeholders endorsed seven of the eight competencies identified in the Taiwanese framework: clinical competence, communication, ethics, humanism, excellence, accountability, and altruism. For the eighth competency, integrity, the Chinese participants preferred the term “morality.” They also added the competencies of teamwork, self-management, health promotion, and economic considerations. Both frameworks differed from typical Western professionalism frameworks in

Over the past two decades, leading

organizations and scholars have called international attention to the topic of medical professionalism. Numerous reports have described what constitutes professionalism1–6 and how it may be assessed.7–9 Initial discourses portrayed Western ideas on medical professionalism as global and comprehensive through statements such as “the fundamental and universal principles and values of professionalism.”4 Non-Western countries adopted these themes and values accordingly. The Accreditation Council for Graduate Medical Education, International Division (ACGME-I), for example, facilitated Please see the end of this article for information about the authors. Correspondence should be addressed to Dr. Ho, Department of Social Medicine, National Taiwan University College of Medicine, No. 1, Ren-Ai Road, Section 1, Taipei, Taiwan; telephone: (011) ­­­­886910188399; e-mail: [email protected]. Acad Med. 2014;89:944–950. First published online April 18, 2014 doi: 10.1097/ACM.0000000000000240

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the introduction of Western standards, including guidelines for professionalism, into residency programs in Singapore.10 Several other Asian countries referenced ACGME documents in establishing their own domestic accreditation criteria in postgraduate training programs.11 As the medical field becomes increasingly globalized, this notion of Western medical professionalism’s universality merits further investigation. Professionalism is a complex, multidimensional social construct,3,7 and its determination criteria are context dependent.12 A panoply of professional expectations exist, and these standards appear to differ across cultures and countries.13,14 Although many publications address medical professionalism, few examine professionalism within Eastern cultures. The studies that compare medical professionalism frameworks between Western and Eastern countries have identified substantial cultural differences; for example, Taiwanese culture emphasizes personal integrity and social relations to a greater degree than the West.15,16 Other

emphasizing morality and the integration of social and personal roles. Conclusions The resemblance between the Chinese and Taiwanese frameworks in the prominence of morality and integrity suggests the influence of Confucianism. The exclusively Chinese articulations of teamwork, health promotion, and economic considerations appear to derive from social, political, and economic factors unique to Mainland China. This study demonstrates the dynamic influence of cultural values, social history, and health care systems on the construction of medical professionalism frameworks and calls for further research to adapt global frameworks to fit specific local contexts.

studies in Hong Kong17 and China18 also noted an influence of Chinese values on medical professionalism. These studies raise a question of whether other differences in framing professionalism exist among East Asian medical schools. Hofstede’s19 cultural dimensions theory provides a framework for comparing values between national cultures. He notes that “values are an attribute … of collectivities; culture presupposes a collectivity.” Because medical professionalism is a social construct, the collective values of given societies should form their construct of medical professionalism. Although Hofstede’s use of countries as a unit of analysis becomes complicated when analyzing regions with substantial intranational variations in culture, his construction of values as a social dimension facilitates a comparison of medical professionalism in distinct regions with common cultural roots. His findings are partially supported by Schwartz’s20 research on cultural values, which revealed not only differences between the values of North Americans, Europeans, Asians,

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etc., but also appreciable interregional differences in values among Mainland China, Hong Kong, and Taiwan. Despite their common cultural heritage, Mainland China and Taiwan differ culturally largely because of their distinctive political histories. Most notably, though grounded in Chinese culture dating back centuries, modern Taiwan grew from the events following the Chinese Civil War when the armies and central government of the Republic of China retreated to Taiwan. Divergences in medical professionalism between Chinese and Taiwanese medical schools have significant implications for medical curriculum and medical school accreditation in these regions, as well as for other countries with significant Chinese immigrant populations, given the number of international medical graduates from China. As part of a larger study on cross-cultural medical professionalism, earlier research on categories of medical professionalism helped to enhance our understanding of cultural differences between Mainland Chinese and Western populations. For instance, research demonstrated that "morality" is central to the Chinese medical professionalism framework.18 To date, however, no published research has compared medical professionalism solely between Eastern cultures. In this study, we compare stakeholders’ definitions of medical professionalism in two Chinese cultural contexts—Peking Union Medical College (PUMC) in Beijing, China, and National Taiwan University College of Medicine (NTUCM) in Taipei, Taiwan. These two schools and their affiliated hospitals are historically prominent medical institutions in their respective settings and could represent aspired medical professionalism. We sought to address the following research questions: (1) What values do Chinese and Taiwanese stakeholders articulate when constructing “medical professionalism”? (2) What similarities exist between these two cultural contexts, both rooted in the Chinese tradition? (3) What are the differences arising through dissimilar social histories and medical systems? Method

Participants This study was conducted using a stratified convenience sample of 97 participants

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at PUMC in November and December 2011. Participants were recruited either in person or over the phone via a key informant in their field (e.g., program director) by a member of the research team (H.P.) and then placed into 1 of 13 groups sorted by occupation: attending physician, chief resident, resident physician, head nurse, nurse, nursing student, medical student, graduate student with a first medical degree (abbreviated as graduate student), medical humanities educator, public health expert, medical school administrator, standardized patient, and hospital volunteer. The demographic data have been presented previously.18 The research ethics committee of PUMC determined this study exempt from review. Data collection We employed a modified nominal group technique (NGT)21 to determine PUMC’s valued concepts of medical professionalism and compared the PUMC framework with a framework previously developed at NTUCM15 with the NGT. We chose the NGT because it is an efficient and effective method to reach group consensus and is more socially and emotionally satisfying than other consensus methods such as Delphi in which participants do not meet.15,21 This method ensures that all participants have equal vote and that all group members have equal opportunities to express their views, minimizing common pitfalls of group meetings such as dominant personalities or deference to authorities.15,21 NGT meetings were held in Mandarin by individual occupational groups, facilitated by two of the authors (M.H. and J.L.), and lasted between 40 minutes and 1 hour. Participants were offered refreshments as compensation. There were five steps in the NGT procedure. First, each participant wrote down on individual sticky notes what he or she considered the essential abilities of a professional doctor, reflecting their expectations of medical professionalism. Second, participants named each of their items one at a time in a ­round-robin format, without repeating any previously mentioned items, until all items had been stated. Third, participants posted their notes on a blackboard individually under the categories they believed most appropriate: integrity, humanism, excellence, accountability, altruism, ethics, communication, and clinical competence. These categories were

determined from the previous NGT study at NTUCM.15 Participants could formulate new categories if the existing categories were not suitable. In step four, participants each chose the five items they considered most important and ranked them on a Likert scale, where 1 = least important and 5 = most important. In the final step, voting results were added up across participants in each group, and the items were ranked to determine results for that group. Data analysis Three of us (M.H., Y.L., J.C.) recorded, transcribed, and anonymized the NGT meetings. Transcripts amounted to 85 pages and contained 68,379 Chinese characters. Three of us (M.H., K.Y., Y.L.) then analyzed the transcripts to identify themes and to compare them with the NTUCM framework.15 Finally, three of us (M.H., K.Y., H.P.) constructed a pictorial framework containing the main themes in the transcripts and the categories created by the NGT groups as the PUMC framework. The visual framework modeled the shape of historical buildings of PUMC and was inspired by Stern’s8 pictorial framework of professionalism. Key words in the framework were originally in Chinese and translated into English. Results

Each nominal group at PUMC listed 11 to 19 items that they considered essential to medical professionalism. The majority of these items could be categorized into the eight competencies, listed earlier, that we identified and described in greater detail in the previous study at NTUCM15 (see Figure 1). The PUMC visual framework for medical professionalism (see Figure 2) differed from the NTUCM framework (Figure 1) in replacing integrity with morality. Further, the PUMC framework identified four additional distinct competencies: teamwork (which the NTUCM framework incorporated into accountability); self-management; health promotion; and economic considerations. The NTUCM framework left blank columns for personal goals (including self-management) and did not specify health promotion or economic considerations. In Table 1, we present exemplary quotations (translated into English from Chinese

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management, and crisis management. Although Taiwanese participants discussed several self-management issues, they sought to place these elements in the blank columns as personal values in Figure 1. In contrast, the Chinese participants created a category for self-management and differed from the Taiwanese in articulating ­­­­“selfprotection.” All Chinese physician groups mentioned that doctors should protect themselves, but of note, a physician in Beijing had been severely stabbed by a patient shortly before the NGT meeting,22 potentially influencing participants’ emphasis on this item. Participants also referenced legal understanding as a form of self-protection in avoiding disputes. Health promotion

Figure 1 National Taiwan University College of Medicine’s framework for medical professionalism.15 Adapted from Stern DT. Measuring Medical Professionalism. New York, NY: Oxford University Press; 2005. By permission of Oxford University Press, Inc. (www.oup.com).

transcripts) to characterize the differences in categories between the PUMC and NTUCM frameworks. In the following sections, we examine these categories— morality, teamwork, self-management, health promotion, and economic considerations—in more detail.

illustrate the paramount significance of morality in medical professionalism. Some participants referenced the communist value of integrating morality and specialty using the phrase 又紅又專 (you hong you zhuan, literally translated as “both red and expert”).

Morality

Teamwork

The NTUCM framework granted a central role to “integrity,” a concept suggesting adherence to one’s principles; the PUMC participants recognized this concept but suggested a broader concept of “morality,” which incorporated humanistic values and the cultivation of one’s character. Numerous participants commented on the importance of morality, and several participants prioritized morality over clinical competence. Furthermore, several participants used Confucian moral concepts such as “仁愛” (ren ai, humane love), “厚德載物” (hou de zai wu, great morality holds everything), “公心” (gong xin, public-spirited), and “慎獨” (shen du, prudent in privacy or “Do on the hill as you would do in the hall”) to

All PUMC groups listed teamwork as an important competence. Most participants viewed teamwork as the ability to cooperate to accomplish common goals in providing health care. Participants emphasized the importance of teamwork by featuring it as an independent item in the PUMC framework, rather than as a constituent of accountability, as in the NTUCM framework. Several participants articulated that teamwork denoted mutual professional support.

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Self-management Both Taiwanese and Chinese participants listed multiple items under the theme of self-management, including emotional management, time management, health

At PUMC, the public health expert and attending physician groups both considered “health promotion” an essential competency for medical professionals. These groups were conscious of addressing the knowledge gap between physicians and patients. Public health experts also mentioned that physicians should prevent epidemics not only by educating their patients but also by following precautions themselves. Economic considerations PUMC participants referenced attentiveness to economic considerations as an essential competency, such as the importance of attending to patients’ economic difficulties. As the quotation about economic considerations in Table 1 illustrates, Chinese patients are concerned that doctors might augment their incomes by prescribing profitable drugs. Some participants praised the comprehensive health insurance system in Taiwan and expressed hope for improvement in the Chinese health system. In addition, the physician group mentioned that doctors should consider financial challenges facing hospitals. As an illustration, a chief resident stated that “physicians should achieve maximum therapeutic effects with minimum economic cost to their patients and hospitals.” Discussion

This is a cross-cultural study of medical professionalism in two Chinese contexts. Previous studies have shown that people in different cultures have distinct concepts of medical professionalism.7,14,15,23–25 To

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Some PUMC participants explained the emphasis on morality by referencing its preeminence in traditional Chinese culture.19 One participant cited the PUMC motto: 厚德載物 (hou de zai wu), which can be translated as “great morality holds everything” and originates from the Confucian classic 易經 (I-Ching).30

Figure 2 Peking Union Medical College’s (PUMC) framework for medical professionalism. These competencies were identified by 97 PUMC participants in nominal group technique exercises taking place from November to December 2011, mapped onto the National Taiwan University College of Medicine’s framework for medical professionalism (see Figure 1).

our knowledge, our study is the first to compare medical professionalism in two settings sharing Chinese cultural roots. We employed the NGT method to construct frameworks of medical professionalism at historically prominent medical schools in China and Taiwan. The similarities in the centrality of morality and integrity to both frameworks could be explained by cultural theory,19 but the differences between morality and integrity call for further explanation beyond this scope.26 Similarities and cultural values The PUMC and NTUCM frameworks both valued clinical competence and competence in communication— dimensions similar to the foundation of the Western framework as formulated by Stern.8 This may suggest either that Eastern and Western cultures both share these values or that medical professionalism has been effectively globalized.14 Other values shared with the Western frameworks were ethics, humanism, excellence, accountability, and altruism. The PUMC and NTUCM frameworks both differed from typical Western frameworks in their emphasis on morality and the integration of social and personal

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roles. These differences suggest the influence of traditional Chinese culture, particularly Confucianism, on the construction of medical professionalism. In Confucianism, to be a “君子” (junzi, virtuous man) is of utmost importance. Being a junzi essentially means upholding a high moral standard and maintaining integrity even when no one is around, as a participant illustrated with the phrase “慎獨” (shen du, prudence in privacy). In the Analects, the most important Confucian text, Confucius used the word “junzi” more than 90 times.27 Hofstede19 notes that these types of moral values may be more common to “organizations where collectivist values prevail,” such as in Taiwan and Mainland China. Taiwanese people study the Analects from primary school onward, rendering Confucianism the most influential moral teaching in Taiwanese society.28 During the Cultural Revolution (1966–1976) in Mainland China, leaders criticized Confucianism; however, the philosophy has been revived in recent years,29 and numerous participants at PUMC mentioned the importance of maintaining high moral standards.

Additional evidence of Confucianism’s influence in medical professionalism19 showed in both the NTUCM and PUMC frameworks’ emphases on harmonizing personal and social roles, through participants’ articulations of gong xin (public-spiritedness) and ren ai (humane love). The Chinese character for ren consists of two pictorial symbols, “two” and “person,” denoting the importance of personal relations in Confucian morality. A previous study found that in reaction to professionalism dilemmas, Taiwanese medical students differed from Western students in focusing more on social relations; this may be attributed to the influence of Confucian relationalism,16 which Hofstede19 also associates with collectivism and Schwartz20 with conservatism. Confucian scholar Yuli Liu31 notes that [t]he individual is always considered as a person-in-society in Confucianism, existing in a network of relations.… For example, that a son should be filial to his parent is not only an obligation; the son fulfils it not solely for the sake of the parent, but also because this is what he owes to his own moral integrity. By this act, he proves to himself, as well as to others, that his claims to true personhood are valid.

By contrast, Western professionalism frameworks generally focus on professional factors and rarely address personal influences. For instance, the Canadian framework for essential physician competencies, CanMEDS, included seven professional factors and deliberately excluded an earlier item, “physician as a person.”32 Social roles are integral to Confucian-based Chinese culture and may affect how Chinese societies interpret medical professionalism. Differences and social context Participants articulated dissimilar social histories to explain the differences in medical professionalism between PUMC and NTUCM. Some PUMC participants articulated the phrase 又紅又專 (you hong you zhuan), literally translated as “both red and expert.” Originated from Mao’s33

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Table 1 Representative Quotations Describing the Items From PUMC’s Medical Professionalism Framework That Differed From the Items in NTUCM’s Framework Theme

Quotations from NGT transcripts

Morality

Integrity is part of morality. In Mainland China, we generally use the term morality.… The same concept may be referred to by a different term in Taiwan. (Medical ethics expert) In my opinion, only if one has good moral character can one’s decision benefit others, including patients and other medical professionals. Only then would his or her decision work in the right direction. (Attending physician) Competent physicians may harm society if their professional conduct is immoral. It is true that clinical skills are important; however, building professional morality is the top priority. (Attending physician) [M]orality refers to general moral character, which we all should possess. Ethics refers to ethical principles applied to medical practice, which we can learn. We must learn what can and cannot be done according to medical ethics. (Medical student)

Teamwork

Teamwork has two aspects: One is collaboration with others to do things better; the other is not to pull the rug from under other providers’ feet in front of the patients. This is also a way to collaborate. (Chief resident)

Self-management

Clinicians should first learn how to protect themselves so that they can help others. In fact, when I am in the clinics now, the first thing in my mind is how to avoid disputes. After this consideration, I would start to think about how to provide the best service to the patient.… I think it is an important aspect in Mainland China in these days. (Attending physician) [P]atients have high legal awareness nowadays, so physicians should have the same awareness as well. (Medical ethics expert)

Health promotion

I think a good doctor should popularize his or her knowledge, especially by using plain language in an understandable style. They should go to the community to propagate medical knowledge to the masses. (Physician) I think doctors should be aware of how to protect themselves from diseases because they contact lots of patients with infectious diseases. Clinicians cannot fall prey to epidemics in the first place. (Public health expert)

Economic considerations

[M]y doctor should consider several aspects of my problem, including economic ones. If a drug that cost 0.2 dollars had the same remedial effects as another that cost more than 200 dollars, it is more suitable to prescribe the former. It would be difficult to change this situation because some physicians care mostly about their own income. (Standardized patient) A physician should pay attention to economic issues. That is to say, the doctor should achieve maximum therapeutic effects with minimum economic cost to patients and hospitals. (Chief resident)

Abbreviations: PUMC indicates Peking University Medical College; NTUCM, National Taiwan University College of Medicine; NGT, nominal group technique.

oration to the eighth Central Committee meeting of the Communist Party of China in 1957, the phrase means “both communist-minded and professionally competent.” Chinese students are expected to develop a proletarian moral character (a collectivist value)19 while acquiring technical knowledge in their specialty. The influence of communism also imbues the PUMC medical professionalism framework when identifying teamwork as an independent competency in promoting health for the masses. PUMC participants also discussed differences between Taiwanese and

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Chinese medical professionalism related to the health systems in both countries, which might explain why PUMC participants discussed “economic considerations” while NTUCM participants did not. Whereas the Taiwanese population enjoys comprehensive coverage by the National Health Insurance system,34 the Chinese population cannot rely on the country’s fledgling health insurance system to cover substantial treatment.35 Furthermore, the salaries of Chinese physicians are relatively low compared with most other countries, and also in comparison with other professions

in China.36 In our study, patients are concerned that doctors might augment their incomes by prescribing profitable drugs. The physician group openly discussed this public distrust of medical professionals and stipulated that doctors must be able to protect themselves from patients’ assaults arising from distrust and misunderstanding. Economic struggles faced by both patients and doctors under the health care system might also exist outside of China37 and may influence patient and physician feelings of vulnerability and trust. Even as current medical professionalism literature derives from scholars in nations with more extensive health care resources, in other contexts, the influence of economic factors on medical professionalism offers an area of future research. NGT and democratic research methods In addition to broadening the contextual scope of medical professionalism, our study offers a cross-cultural view of the NGT methodology’s suitability for research on medical professionalism. We did not know at the outset how the NGT’s democratic process would function with participants from a society with limited democracy. We did not see issues, such as deferring to hierarchy, impede the NGT’s utility. Indeed, in our study the NGT elicited rich discussion and prompted participants to reveal what they knew about local deficiencies in medical professionalism. Because these deficiencies carry implications for medical education, methods such as the NGT that generate open discourse may offer additional value. For instance, the only groups in our study that prioritized ethics were those comprising experts or graduate students with a first medical degree. This observation indicates room for improvement in raising awareness of medical ethics among all stakeholders. Limitations Our study only included participants from a single institution in China, a large country with 630 medical schools offering a range of medical education programs with different focuses (e.g., rural workforce, physician scientists) and duration (ranging from three to eight years).38 Further studies, assessing other types of programs and other parts of the country, would be

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required to determine whether PUMC stakeholders’ expectations for medical professionalism reflect the ideals of other Chinese institutions. Also, although the majority of the moderators were not affiliated with PUMC, some of the authors moderated the NGT meetings; thus, it is possible that their presence could have influenced participants’ responses. Another limitation was that we modified Step 3 of the NGT process to facilitate comparisons among groups and between the Taiwanese and Chinese institutions. We provided PUMC participants with NTUCM’s existing framework as a starting point for categorization, and this may have influenced PUMC’s framework formulation. Nevertheless, participants expressed their views and added new categories, and our pilot studies using an unmodified NGT approach at PUMC generated similar categories. Finally, because the transcripts were translated from Mandarin to English in drafting this manuscript, subtleties may be subject to interpretation or lost altogether. To address this possibility, one author, M.H., a bicultural, bilingual, trained anthropologist reviewed all translations for accuracy and for attention to subtle meanings. Future studies should employ additional research methods to triangulate these findings.

Funding/Support: This study was funded by the National Science Council of Taiwan; the Ministry of Education, Republic of China; and the Ministry of Education, People’s Republic of China. Other disclosures: None reported. Ethical approval: The study protocol was determined exempt from review by the research ethics committee of Peking Union Medical College. Previous presentations: Ho M, Liang Y, Pan H, Li J, Hirsh D. A cross-cultural study of medical professionalism in two Chinese cultural contexts. Presented at the 2012 Association of American Medical Colleges annual meeting, San Francisco, California. Dr. Ho is assistant dean for international affairs and professor, Department of Social Medicine, National Taiwan University College of Medicine, Taipei, Taiwan. Dr. Yu is a PhD student, Biomedical Informatics Training Program, Stanford University School of Medicine, Stanford, California. Dr. Pan is professor, Department of Endocrinology and Metabolism, and vice director, Department of Education, Peking Union Medical College Hospital, Beijing, China. Ms. Norris is a research assistant, National Taiwan University College of Medicine, Taipei, Taiwan. Ms. Liang is a research assistant, National Taiwan University College of Medicine, Taipei, Taiwan. Ms. Li is an MD candidate, Peking Union Medical College, Beijing, China. Dr. Hirsh is associate professor Harvard Medical School, Boston, Massachusetts, and Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts.

Conclusions

References

We used a modified NGT to compare medical professionalism constructs at two institutions with distinct Chinese cultural contexts. This process generated a medical professionalism framework for PUMC and demonstrated the utility of the NGT in environments with limited democracy. The findings underscore that medical professionalism is a complex social construct shaped by local values and that it cannot be solely defined by universal standards. National and regional influences and memes shape a “microculture” through a dynamic interplay of cultural, social, and health care system factors. Future research should probe further into the manner by which constructs of medical professionalism arise to fit specific contexts.

1 Cruess RL, Cruess SR. Teaching medicine as a profession in the service of healing. Acad Med. 1997;72:941–952. 2 Cruess RL, Cruess SR, Steinert Y. Teaching Medical Professionalism. New York, NY: Cambridge University Press; 2009. 3 Cruess SR. Professionalism and medicine’s social contract with society. Clin Orthop Relat Res. 2006;449:170–176. 4 ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med. 2002;136:243–246. 5 Blank L, Kimball H, McDonald W, Merino J. Medical professionalism in the new millennium: A physicians’ charter 15 months later. Ann Intern Med. 2003;138:839–841. 6 Swick HM. Toward a normative definition of medical professionalism. Acad Med. 2000;75:612–616. 7 Hodges BD, Ginsburg S, Cruess R, et al. Assessment of professionalism: Recommendations from the Ottawa 2010 Conference. Med Teach. 2011;33:354–363. 8 Stern DT. Measuring Medical Professionalism. New York, NY: Oxford University Press; 2006.

Acknowledgments: The authors would like to thank all of the participants of the nominal group technique meetings.

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9 Arnold L. Assessing professional behavior: Yesterday, today, and tomorrow. Acad Med. 2002;77:502–515. 10 ACGME-International Web site. 2011. ­­­­http:// www.acgme-i.org/web/index.html. Accessed February 12, 2014. 11 Lee SS, Chiang HC, Chen MC, et al. Experiences of interprofessional implementation of a healthcare matrix. Kaohsiung J Med Sci. 2008;24:634–639. 12 Ginsburg S, Regehr G, Hatala R, et al. Context, conflict, and resolution: A new conceptual framework for evaluating professionalism. Acad Med. 2000;75(10 suppl):S6–S11. 13 Cruess SR, Cruess RL, Steinert Y. Teaching professionalism across cultural and national borders: Lessons learned from an AMEE workshop. Med Teach. 2010;32:371–374. 14 Chandratilake M, McAleer S, Gibson J. Cultural similarities and differences in medical professionalism: A multi-region study. Med Educ. 2012;46:257–266. 15 Ho MJ, Yu KH, Hirsh D, Huang TS, Yang PC. Does one size fit all? Building a framework for medical professionalism. Acad Med. 2011;86:1407–1414. 16 Ho MJ, Lin CW, Chiu YT, Lingard L, Ginsburg S. A cross-cultural study of students’ approaches to professional dilemmas: Sticks or ripples. Med Educ. 2012;46:245–256. 17 Leung DC, Hsu EK, Hui EC. Perceptions of professional attributes in medicine: A qualitative study in Hong Kong. Hong Kong Med J. 2012;18:318–324. 18 Pan H, Norris JL, Liang YS, Li JN, Ho MJ. Building a professionalism framework for healthcare providers in China: A nominal group technique study. Med Teach. 2013;35:e1531–e1536. 19 Hofstede G. Culture’s Consequences: International Differences in Work-Related Values. Vol 5. Newbury Park, Calif: SAGE Publications; 1980. 20 Schwartz SH. A theory of cultural values and some implications for work. Appl Psychol Int Rev. 1999;48:23–47. 21 Gallagher M, Hares T, Spencer J, Bradshaw C, Webb I. The nominal group technique: A research tool for general practice? Fam Pract. 1993;10:76–81. 22 China Medical Tribune Web site. 2013. http:// zt.cmt.com.cn/zt/xuwenaffairs/index.html. Accessed February 12, 2014. 23 Tsai SL, Ho MJ, Hirsh D, Kern DE. Defiance, compliance, or alliance? How we developed a medical professionalism curriculum that deliberately connects to cultural context. Med Teach. 2012;34:614–617. 24 Ho MJ. Culturally sensitive medical professionalism. Acad Med. 2013;88:1014. 25 Al-Eraky MM, Chandratilake M, Wajid G, Donkers J, van Merrienboer J. Medical professionalism: Development and validation of the Arabian LAMPS. Med Teach. 2013;35(suppl 1):S56–S62. 26 McSweeney B. Hofstede’s model of national cultural differences and their consequences: A triumph of faith—a failure of analysis. Hum Relat. 2002;55:89–118. 27 Disciples of Confucius. The Analects of Confucius. New York, NY: Columbia University Press; 2006. 28 Yao X. An Introduction to Confucianism. Cambridge, UK: Cambridge University Press; 2000.

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Teaching and Learning Moments Deep Listening

According to the literature, good communication skills are associated with stronger patient–doctor relationships, greater patient satisfaction, and better compliance. As a medical student, I am also frequently reminded that they are a way to avoid lawsuits. Patients do not sue doctors they like! I have heard much about how these skills can impact one’s medical practice but less about how they can relieve suffering. I met Ms. Kay in the emergency department during a rural family medicine rotation in western North Carolina. She was in her mid-60s, had smoked three packs of cigarettes a day since her late teens, and was emaciated after losing 80 pounds in the last six months. She was experiencing night sweats and profound anorexia, even losing her taste for cigarettes. Her chief complaint, though, was that she was constipated. She had not defecated in over a week, despite only eating one full meal during that time. As a first-year, my clinical medicine professor had a rule: Sit down with every patient you see. There were two reasons for this rule: (1) It is more comfortable, and (2) patients feel more at ease. Never act like you are in a hurry, Robert, even if you are. She also told me to try to let patients talk for as long as they want, without interruption, to get the full story.

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So I sat down and listened. Within a few minutes, I knew she had cancer. Pressing on her belly, I could feel metastases in her liver. The organ was nodular, palpable from the splenic flexure to deep in her right lower quadrant. Her breath was fetid. Her lungs were that of a heavy smoker’s. A few hours later, when we had confirmation, I told Ms. Kay and her husband that she had cancer—in her liver, lungs, and colon. The colon carcinoma, which was almost completely blocking the passage of stool, was the source of her constipation. I told them gently that there would be no easy fix. It was a matter of time. Ms. Kay did not say much, but her husband was angry. He was angry not because of the diagnosis but because, in the last two months, they had seen their primary care doctor, gone to an urgent care center, and visited this very same emergency room. Each time Ms. Kay was sent home with laxatives. Once she had an x-ray and was manually disimpacted, but she never received any follow-up. Driving home that evening I was angry too. Clearly, somewhere along the line, the medical community had dropped the ball. Either we did not listen or we skipped the physical exam entirely. Ms. Kay’s liver was most assuredly not normal two months ago. Even if they had found her cancer

then, there was probably nothing that could have been done. Yet, she had spent the last two months suffering needlessly. I know I will miss diagnoses during my career. I am going to drop the ball; I will make mistakes. I just hope it is never because I did not listen. Communication skills are not just about outcomes, satisfaction scores, and lawsuits. We listen to relieve suffering. Deep listening and loving speech are wonderful instruments to help us arrive at the kind of understanding we all need as a basis for appropriate action. You listen deeply for only one purpose—to allow the other person to empty his or her heart. —Thich Nhat Hanh Author’s Note: The name in this essay has been changed to protect the identity of the patient. Robert A. Swendiman Mr. Swendiman is a fourth-year medical student, University of North Carolina School of Medicine, Chapel Hill, North Carolina. He is currently working towards a master of public policy at the Harvard Kennedy School of Government and is Dubin Fellow for Emerging Leaders, Center for Public Leadership, Harvard University, Cambridge, Massachusetts; e-mail: [email protected].

Academic Medicine, Vol. 89, No. 6 / June 2014

A tale of two cities: understanding the differences in medical professionalism between two Chinese cultural contexts.

To compare stakeholders' constructs of medical professionalism in two Chinese cultural contexts...
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